Jan 10 The Deep Disparities of Unintended Pregnancies: A Case for Women’s Health and Reproductive Empowerment

Did you know that poor women are nearly six times more likely to experience an unintended pregnancy than women with greater socioeconomic status?1 A recent study by the New England Journal of Medicine discovered that women who are not high school graduates are also three times more likely to have an unintended pregnancy than women who are college graduates.2 Likewise, every 79 pregnancies per 1,000 non-Hispanic black women, 58 pregnancies per 1,000 Hispanic women, and 33 pregnancies per 1,000 non-Hispanic white women are unintended.2 Herein resides the deep disparities of unintended pregnancies. Why is a woman’s reproductive outcome, specifically the possibility of an unintended pregnancy, disproportionately determined by her income, education, and ethnicity?

An unintended pregnancy is defined as either mistimed–the pregnancy is not desired at the time, though possibly at a future date–or unwanted.1 The incidence of unintended pregnancies has served as a vital indicator of reproductive health for women ages 15-44 at the national level since the 1980s.2 A woman’s ability to choose if or when a pregnancy occurs in her lifetime is often studied in relation to geopolitical factors, including access to family planning clinics and contraceptives, as well as the regional effects of public policies.2,3 Yet, a woman’s reproductive health, as related to her incidence of unintended pregnancies, is undeniably linked to additional social determinants. National data shows a real and alarming trend for American women in which unintended pregnancies are strongly governed by socioeconomic status and sociodemographic factors, including income, education, and ethnicity.2-5

The National Center for Health Statistics, Healthy People 2020, and the Guttmacher Institute are among the leading health metrics organizations that track the incidence of unintended pregnancies in the United States. The most recent data shows that unintended pregnancies continue to represent a significant portion of the 6.1 million annual pregnancies in the nation.4 In fact, 45% of all pregnancies in 2011 were unintended; surprisingly, this is the lowest incidence ever recorded.3-5 National trends for unintended pregnancies have been on the decline as a whole since 1981, with the exception of a slight rise from 48% to 51% between 2001 and 2008.3-5 Although there seems to be a promising downward trend for women as a whole, there is a stark disparity in unintended pregnancy rates for poor and low-income women.3,5 In 2011, 60% of pregnancies for women that were below the federal poverty line were unintended, compared to 30% for women with an income over twice the federal poverty level.5 On average, every 112 pregnancies per 1,000 poor women are unintended, versus 20 per 1,000 higher-income women.5

The consequences of unintended pregnancies for maternal and child health are far-reaching and can be fatal. In fact, women who experience unintended pregnancies are at in increased risk of maternal depression and physical violence during the pregnancy, in addition to likely experiencing delays in initiating prenatal care.4 Unintended pregnancies are also more likely to result in low-birth weight infants who have poor physical and mental health later in childhood.4 It is notable that 82% of pregnancies for women ages 15-19 are unintended, which is the highest of all age groups.4 Children from unintended pregnancies in this age group are more likely to have lower cognitive attainment and behavioral issues later in life.4 According to Healthy People 2020, the sons of mothers in this age group are more likely to become incarcerated, while daughters are more likely to become adolescent mothers themselves.4

In addition to negative maternal and child health outcomes, unintended pregnancies also constitute a large portion of public expenditures.3,4 In 2010 alone, $21 billion – $14.6 billion in federal and $6.4 billion in state expenditures – was spent to cover the cost of unintended pregnancies, including prenatal care, labor and delivery, postpartum care, and one year of infant care.3,4 Public resources used to cover the cost of unintended pregnancies are also notably highest in regions of the United States with high levels of poverty.3 For example, 82% of unintended pregnancies in Mississippi were paid for by public insurance programs, primarily Medicaid, compared to 68% nationally in 2010.3 During the same year, Mississippi had one of the highest rates of unintended pregnancies of all states in 2010, at 57 per 1,000 women, compared to a low of 32 per 1,000 in New Hampshire and a high of 62 per 1,000 in Delaware.6 Mississippi’s overall poverty rate in 2011 was 22.4%, compared to the national rate of 14.8%, which was the highest poverty rate of all states.7 One of the most disconcerting facts about unintended pregnancies is that even though national trends are on the decline, at this rate over half of all women in America will still experience an unintended pregnancy by the time they reach age 45.6

Yet, the unacceptable disparities and outcomes of unintended pregnancies does not have to be set in stone. If we take the necessary steps to address not only issues of access to family planning clinics and contraceptives, but also the effects of public policy and the social determinants of unintended pregnancies, we can decrease national trends today. In fact, there are already resources and tools in place that are shaping the future of women’s reproductive health to decrease the incidence of unintended pregnancies. Most notably, public insurance programs like Medicaid and the Title X Family Planning Program are crucial for women’s access to affordable contraceptive services and supplies, including the ability to use contraceptives as effectively as possible.6 Although unintended pregnancies are costly to both the state and nation, the costs could have been considerably higher without these public programs.3 In 2014, publicly funded family planning services helped two million women avoid unintended pregnancies.7 This translates to taxpayers saving approximately $13.6 billion, not to mention a decreased incidence of a range of other negative reproductive health outcomes such as HIV, sexually transmitted diseases and infections, cervical cancer, and infertility.3,6

The importance of contraceptive services in particular cannot be understated. Annually, two-thirds of women in America use contraceptives consistently throughout the entire year.6 Women who use contraceptives consistently account for only 5% of all unintended pregnancies, while the remaining 95% of unintended pregnancies are attributed to women who either don’t use contraceptives at all or who use contraceptives inconsistently.6 Furthermore, data shows that following a long period of minimal change for the national rate of unintended pregnancies between 2008 and 2011, there was a significant decrease from 54 to 45 unintended pregnancies per 1,000 women.3 This decline resulted in the lowest rate of unintended pregnancies since at least 1981 and is largely attributable to an overall increase in the use of highly effective contraceptives.3

The data is clear: publicly funded family planning services and programs are essential to preventing unintended pregnancies. Yet, what are the current and future responsibilities of legislators and health care providers in addressing the social determinants of unintended pregnancies and women’s larger reproductive health? What are the bioethical implications that a woman’s socioeconomic status and sociodemographic factors can directly affect her reproductive health and ultimately her sense of reproductive empowerment? At its core, unintended pregnancies are a key reflection of women’s reproductive injustice and lack of empowerment. A woman’s ability to exercise autonomy over her reproductive health is influenced by the development of her personal sense of agency, or the feeling of control she has in making reproductive decisions for her own body. Moreover, her perceived feeling of safety in the home and the clinic is fundamental to developing her sense of reproductive empowerment. The ability to feel safe in the clinic environment is built on trust in the practices and intentions of health care providers, just as much as feeling safe in the home is dependent on healthy relationships with sexual partners, family, and other important support systems. If women have both safety in the clinic and public policies that support access to family planning services and contraceptives, they will be in a better position to exercise autonomy over their reproductive health. Consequently, greater access to vital sexual health services and safety in the clinic will inevitably lead to greater reproductive empowerment.

A deep look at the history of American medicine shows why safety in the clinic is pivotal for shaping a more equitable future in which unintended pregnancies are minimized for women of all income levels, education, and ethnicities. The disparity that exists in women’s health and ethnicity in particular can be traced back to the largely overlooked history of institutional racism in American medicine.8 Since the 1830s, recorded experimentation by doctors in the American medical system was routinely performed to test procedures such as C-sections and the extremely dangerous ovariotomy on enslaved black women.8 According to recent research, approximately 50% of all publications in the 1836 Southern Medical and Surgical Journal used experiments on enslaved black people for their findings.8 One series of intensely painful experimental surgeries conducted on enslaved black women by Dr. James Marion Sims, known as the “father of modern gynecology,” resulted in one of the most insidious beliefs in medicine at that time: that black people did not feel pain or anxiety.8 These false findings are additionally disturbing in conjunction that they continue to haunt the American medical system today. An article published in 2016 by the Departments of Psychology, Family Medicine, and Public Health Sciences at the University of Virginia revealed that,“Black Americans are systematically undertreated for pain relative to white Americans.”9 The findings from this study even came to the conclusion that “individuals with at least some medical training hold and may use false beliefs about biological differences between blacks and whites to inform medical judgments, which may contribute to racial disparities in pain assessment and treatment.”9

Unfortunately, the injustice does not end there. In the early 20th century, the Tuskegee experiments, segregation of hospitals based on the Jim Crow Laws, and the American eugenics movement instilled false narratives and created mistrust of the medical system in many black Americans. More than 60,000 people deemed “undesirable”–a large majority of whom were poor and people of color–were subject to forced sterilizations not long ago under past American eugenics laws.10,11 One example is Fannie Lou Hamer, a prominent civil rights leader, who went to a hospital in 1961 to have a tumor removed, but was instead subjected to a hysterectomy without her consent.8 This procedure, which renders women infertile, was so common in the South at that time that Hamer herself coined it the “Mississippi Appendectomy.”8 It wasn’t until 1973 that the Southern Poverty Law Center revealed up to 150,000 cases of women who had been forcibly sterilized with federal funds in Alabama alone, half of whom were black.8

Reproductive health disparities and historical injustices to poor women of color in America have undoubtedly impacted their sense of safety in the clinic. It’s been found in current literature that minority patients are still more likely to receive lower quality care than non-minority patients even when they have the same types of health insurance or same ability to pay for care.8,12 For instance, the Centers for Disease Control and Prevention reported in 2013 that maternal mortality for black women was 43.5 per 1,000 live births compared to 12.7 per 1,000 live births for white women.8 As a whole, America has had a grave problem when addressing health equity, especially promoting reproductive justice and empowerment for women. The concept of reproductive justice and empowerment is strongly linked with a woman’s sense of agency, a further critical component for the decline of unintended pregnancies. In the wake of a dark history of medical injustices, the movement for women’s reproductive justice aims to reaffirm the innate human right to make and direct one’s own reproductive decisions, including the right to obtain or decline contraceptives and all other forms of women’s health and maternal care services.10,13 The idea of reproductive justice and empowerment naturally accompanies the decline of unintended pregnancies, which requires “the obligation of the government and larger society to create laws, policies, and systems conducive to supporting those decisions.”10

As such, I advocate that women’s health and reproductive empowerment need to become a priority in both public policy and the American healthcare system. Unintended pregnancies are all too often treated by the medical system alone as symptoms of larger disparities in women’s health, namely poverty. However, in order to prevent unintended pregnancies in the future, the root causes must be addressed. The prevention of unintended pregnancies requires a more multifaceted and dynamic approach than current methods, one that precedes the current dedication of resources and public programs on postpartum care, or care for a woman following childbirth. More resources should be devoted to treating the social determinants of unintended pregnancies, including disparities in income, education, and ethnicity for women seeking preconception care, or care before the choice to become pregnant. Public policies that are in alignment with the concepts of reproductive justice and preconception care will be imperative in supporting a future where women are able to make decisions of their own accord without barriers to reproductive healthcare.

The importance of preconception care rests on the fact that it leads to healthier women, which leads to healthier, intended pregnancies. Data from the Guttmacher Institute found that the average American woman wants two children in her lifetime, which requires a total of about three years of being pregnant and postpartum.14 However, the same woman will spend the vast majority of her reproductive years, totaling about three decades, trying to avoid a pregnancy.14 It is evident that improving a woman’s health as a whole before a potential pregnancy is critical for improved reproductive health and a lower overall incidence of unintended pregnancies. Studies have shown that preconception care is not an additional burden to the healthcare provider, as it is already a part of regular primary care for women of reproductive age.15 Preconception care not only addresses improved access to family planning services and contraceptives, but also brings the opportunity for healthcare providers to reframe their implicit biases, by “thinking, counseling, and making decisions in light of the reproductive plans, sexual, and contraceptive practices of the patient.”15,16

Preconception care emphasizes the importance of women’s personal autonomy and safety in the clinic and can simultaneously bring a renewed focus to women as individuals before a potential pregnancy, which is critical for women’s overall reproductive empowerment. The trends for unintended pregnancies in the United States are alarming, but they don’t have to remain a reality. Recognizing the real socioeconomic and sociodemographic disparities that exist in women’s reproductive health outcomes, especially unintended pregnancies, is only the starting point. Changes must be made to both the American medical system and public policies that directly hinder women’s access to family planning services and contraceptives, as well as the ability to receive full preconception care. The incidence of unintended pregnancies for American women is more than a representation of deep disparities and injustices from the past and present. Today it has become inescapable: women’s health and reproductive empowerment are the future.

References

1. “Key Statistics from the National Survey for Family Growth - I Listing.” CDC National

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